Ethical, Legal, and Social Implications
In 2006, Department of Defense Instruction Number 1332.38 (DODINST 1332.38) redefined pre-existing condition as a result of two cases brought by service members who each had a hereditary condition that presented later in their military careers. The disability instructions state that any injury or disease discovered after a service member enters active duty - with the exception of congenital and hereditary conditions - is presumed to have been incurred in the line of duty. Any hereditary and/or genetic disease shall be presumed to have been incurred prior to entry into active duty. However, DODINST 1332.38 further states that any aggravation of that disease, incurred in the line of duty, beyond that determined to be due to natural progression, shall be deemed service aggravated. As a result of these two cases, the 8-year active duty service limit was established. This means that after 8 or more years of military service the natural progression of a genetic condition would be deemed aggravated by military service. Therefore, until late 2008, the presence of a congenital or hereditary condition would not be considered a pre-existing condition in disability decision making for those with 8 or more years of service.
In October 2008, in response to the National Defense Authorization Act of 2008 (NDAA) Title XVI: "Wounded Warrior Matters," a policy memorandum was issued providing supplemental and clarifying guidance on implementing disability-related provisions, including new language related to hereditary or genetic diseases. The policy memorandum states, "Any hereditary or genetic disease shall be evaluated to determine whether clear and unmistakable evidence demonstrates that the disability existed before the Service member's entrance on active duty and was not aggravated by military service. However, even if the conclusion is that the disability was incurred prior to entry on active duty, any aggravation of that disease, incurred while the member is entitled to basic pay, beyond that determined to be due to natural progression shall be determined to be service aggravated." The interpretation of this policy is uncertain at this time.
Case scenarios involving ELSI issues in cancer genetic testing
There are multiple psychosocial, ethical, and legal issues to consider in cancer genetic testing. Genetic tests for germline mutations have social and family implications. In addition to prevention and surveillance options, genetic testing should be offered in conjunction with genetic education and counseling.[18,19] A comprehensive strategy for dealing with ethical dilemmas can incorporate a shared approach to decision-making including open discussion, planning, and involvement of the family. To integrate the different perspectives of bioethics, law, and psychosocial influences, the following scenarios can help health care providers become familiar with commonly encountered dilemmas; it is imperative, however, that the clinician evaluate each patient and his or her situation on a case-by-case basis. These case scenarios were adopted from "Counseling about Cancer: Strategies for Genetic Counseling;" the in-depth case examples are extensively discussed in the original text.